Dysphagia and Vocal Cord Paralysis after Anterior Cervical Disk Surgery
2004-2-25 R3 郭彥君
Anterior cervical diskectomy (and fusion)
1. Surgical indication
Extrusion of disc and associated ostephytic out growth (spondylosis)
cervical radiculopathy and/or myelopathy
Progressive neurologic deficit; static neurologic deficit with
radicular pain; persistent or recurrent arm pain that failed to response
with conservative treatment
2. Surgical technique
1956 Cloward,1962 Smith and Robinson :anterior cervical
discketomy (ACD) with/without fusion
Collar incision (midline –ant border of SCM) or vertical
incision(along ant border of SCM)
through platysma dissect middle layer of cervical fascia ,bypass
SCM & strap muscles
Blunt dissect carotid sheath and tracheoesophagus bundle
Incise prevertebral fascia ,establish exposed vertebra with spinal
needle and lateral radiograph, dissect longus colli m.
Apply Cloward retractor to expose ant cervical spine with carotid
sheath laterally and tracheoesophagus bundle medially
Remove osteophyte, disk with rongeur and drill under microscope
+/- post longitudinal lig. with curet to expose dura
Apply fusion graft
Close wound with/without drain
3. Complications:Dysphagia, vocal palsy, bleeding, esophageal
perforation, graft extrusion
Dysphagia
Occurrence: more than 80 % of patient undergoing ACD
Causes: Hematoma, deep neck infection, hardware complication
perforation of the pharyx, post operative adhesion between esophagus and
osteochondrosis of the vertebral bodies, vocal palsy
2002 Rajesh Bazaz et al:
Dysphagia decrease significantly by 6 months
Female gender and multiple surgical levels as risk factors
2003 Ahmed M.S.Soliman et al: associated only with age
1997 Ruth E.Martin et al:Videofluoroscopic analysis of 13 patient—
2/13 : (1)reduced pharyngeal wall movement, (2) impaired UES opening (3)
imcomplete epiglottic deflection (4) vallecular,pyriform sinus and post. Pharyngeal
wall residue :prevertebral swelling
3/13 : absent pharyngeal swallow: Sup laryngeal n. injury?
4/13: oral preparatory and oral stage deficit:hypoglossal n injury
compatible with operated vertebrae level
Vocal cord mobility impairment
Hoarsness:edema, hematoma, tearing of vocal cord, dislocation or
ankylosis of an arytenoids cartilage,recurrent laryngeal n. injury
Vocal cord palsy (due to recurrent laryngeal n. injury) :
Incidence:0%~16%
Short-term intubation injury:
excessive cuff pressure in the subglottic space leading to compression
of RLN between cricoid and arytenoids cartilages(1983 Sean B.pepard
et al)
associated with surgery duration, age
During surgery: traumatic division, pinch, overstreching, post operative
edema of perineural tissues, RLN included in ligation of inf. thyroid a.,
direct long-standing pressure by retractors,trauma to cricoarytenoid joint
(Hans Heeneman et al ,1972)
Which side (of approach) is better to decrease injury of RLN?
Consideration of which side of approach:
the side of greatest disease , RLN, comfortable, thoracic duct, esophagus
The vulnerable RLN
Anotomy
An angle relative to sagittal plan inferiolaterally to superiomedially:
R’t :25.00+/- 4.70 ; L’t : 4.70 +/- 3.70 (1996 Nabil et al)
Shorter course or R’t RLN: places it at greater risk(1995 Michael
J.Koriwchak et al)
nonrecurrent RLN :R’t (1%) ; L’t (rare)
Higher incidence of R’t RLN injury: only the study of Robinson et al
Reference:
1. Schmidek & Sweet :Operative Neurosurgical Techniques 4th edition 2000 Vol II (p.
1970~1985)
2. Youmans :Neurological surgery 3rd edition 1990 (p. 2923~2935)
3. Baron EM, Soliman AM, Gaughan JP, Simpson L, Young Dysphagia, hoarseness, and
unilateral true vocal fold motion impairment following anterior cervical diskectomy
and fusion. Ann Otol Rhinol Laryngol. 2003 Nov;112(11):921-6.
4. Netterville JL, Koriwchak MJ, Winkle M, Courey MS, Ossoff RH.Vocal fold paralysis
following the anterior approach to the cervical spine. Ann Otol Rhinol Laryngol. 1996
Feb;105(2):85-91
5. Heeneman H. Vocal cord paralysis following approaches to the anterior cervical spine
Laryngoscope 1973;83:17-21
6. Weisberg NK, Spengler DM, Netterville JL. Stretch-induced nerve injury as a cause of
paralysis secondary to the anterior cervical approach. Otolaryngol Head Neck Surg.
1997 Mar;116(3):317-26.
7. Beutler WJ, Sweeney CA, Connolly PJ. Recurrent laryngeal nerve injury with anterior
cervical spine surgery risk with laterality of surgical approach. Spine. 2001 Jun
15;26(12):1337-42.
8. Ebraheim NA, Lu J, Skie M, Heck BE, Yeasting RA.Vulnerability of the recurrent
laryngeal nerve in the anterior approach to the lower cervical spine. Spine. 1997 Nov
15;22(22):2664-7.
9. Sean B.Peppard,MD Laryngeal injury following short-term incubation Ann Otol
Rhinol Laryngol 92;1983
10. Martin RE, Neary MA, Diamant NE. Dysphagia following anterior cervical spine
surgery. Dysphagia. 1997 Winter;12(1):2-8; discussion 9-10.
11. Rajesh Bazaz,MD Michael J.Lee Incidence of Dysphagia after anterior cervical spine
surgery Spine 27(22):2453-2458
12. Liguoro D, Vital JM, Guerin J, Senegas J. Anatomical basis of the anterior cervical
spine approach: topographic study of the nerve structure. Surg Radiol Anat.
1992;14(3):203-8.
0
